Society of St. Vincent De Paul Dental Assistance Program

SOCIETY OF ST. VINCENT DE PAUL DENTAL ASSISTANCE PROGRAM

PATIENT WAIVER AND RELEASE

Please read the following statements and initial each line, then sign and date at bottom of page

▼Read each statement and Initial each blank.

______I understand that I will need to provide personal information that includes but is not limited to medical, dental, and financial information to anyone involved in your dental treatment.

______I give permission to the Society of St. Vincent De Paul to share pertinent information about my eligibility with one or more volunteer dentist in the SVDP-Capital Area Dental Foundation (SVDP-CADF) program.

______I realize that even though I will be referred to the SVDP-CADF dental program for an examination or that I will be accepted as a patient following an examination. I may be dropped at any time due to non-compliance with the guidelines.

______I further understand that the dentist, not the Society of St. Vincent de Paul nor the Capitol Area Dental Foundation, is solely responsible for diagnosis and any possible treatment that I might receive for my dental needs. I release and waive any and all claims arising from or associated with this program that I may assert against the Society of St. Vincent De Paul and/or the Capitol Area Dental Foundation. Other than enforcing the policies and procedures created by SVDP for the purpose of participation within this program, SVDP shall have no legally binding relationship with the client/patient.

______I understand that the dentist(s) have volunteered to only treat my existing dental condition and are not obligated to provide donated care in the future or to retain me as a patient.

______I understand that I must accept the treatment plan the volunteer dentist has decided for me. If I do not accept the treatment plan, I have the option to drop out of the program.

______I understand that the SVDP-CADF program is intended to provide emergency dental care in order to possibly save teeth and remove infection, and this program is NOT created for the purpose of comprehensive, ongoing dental care, including but not limited to, root canals, implants, veneers, bleaching, deep cleaning and other dental procedures in the treatment plan. The goal of the program is to improve dental health that may be classified as an ‘emergency,’ and as such, allow the patient to avoid being forced to receive care from an emergency room or other critical care institution.

______I understand that the SVDP-CADF program can refuse dental services to anyone at anytime.

______If I miss an appointment without a 24 hour notice or if I’m disrespectful, argumentative or conduct myself inappropriately at any time during the treatment, I will be automatically dropped from the program.

Signature below and initials above indicate acknowledgement and agreement to the terms set forth herein.

Signature of client:Date:

Signature of client's guardian:Date:

(If applicable

Signature of witness______Date______